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Background/Aims: Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) is essential in diagnosing solid pancreatic lesions (SPLs), but without rapid on-site evaluation (ROSE), a repeat EUS-FNA/B is crucial for clarifying an inconclusive diagnosis. We aimed to evaluate factors associated with improved diagnostic performance of repeat EUS-FNA/B for initially inconclusive SPL diagnoses without ROSE. Methods: Of 5,894 patients subjected to EUS-FNA/B, 237 (4.0%) with an initially inconclusive diagnosis of SPLs were retrospectively enrolled from five tertiary medical centers between January 2016 and June 2021. Diagnostic performance and procedural factors of EUS-FNA/B were analyzed. Results: The diagnostic accuracies of first and repeat EUS-FNA/B were 96.2% and 67.6%, respectively. Of 237 patients with an inconclusive diagnosis from initial EUS-FNA/B, 150 were pathologically diagnosed after repeat EUS-FNA/B. In multivariate analysis of repeat EUS-FNA/B, tumor location (body/tail vs head: odds ratio [OR], 3.74; 95% confidence interval [CI], 1.48 to 9.46), number of needle passes (≥4 vs ≤3: OR, 4.80; 95% CI, 1.44 to 15.99), needle type (FNB vs FNA: OR, 3.26; 95% CI, 1.44 to 7.36), needle size (22 gauge vs 19/20 gauge: OR, 2.35; 95% CI, 1.19 to 4.62), and suction method (suction vs others: OR, 5.19; 95% CI, 1.30 to 20.75) were associated with a significantly improved diagnostic performance. Conclusions: Repeat EUS-FNA/B is essential for patients with an inconclusive EUS-FNA/B without ROSE. To improve the diagnostic performance of repeated EUS-FNA/B, it is recommended that 22-gauge FNB needles, ≥4 needle passes, and suction methods are used. [ABSTRACT FROM AUTHOR]

Background/Aims: There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. Methods: Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. Results: A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of IDRFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. Conclusions: Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure. [ABSTRACT FROM AUTHOR]

Background/Aims: The endoscopic step-up approach is accepted as the preferred treatment for complicated or symptomatic walled-off necrosis (WON). Direct endoscopic necrosectomy (DEN) is an effective therapeutic option, but few reports describe long-term follow-up in this patient population. Thus, we aim to assess the long-term outcomes of DEN following severe necrotizing pancreatitis. Methods: The data of all acute pancreatitis patients who underwent DEN following endoscopic transmural drainage from six referral centers between 2007 and 2017 were retrospectively collected. Results: Sixty patients (76.7% male, mean age 48.3 years) underwent a median of 4 sessions of DEN starting at a median of 45.5 days after the onset of acute pancreatitis. Clinical success was achieved in 51 patients (85%), with a 35% complication rate and a 5% mortality rate. Using multivariate analysis, the risk factor associated with DEN failure or major DEN complications requiring intervention or surgery was an identified bacterial/fungal WON infection (odds ratio, 19.3; 95% confidence interval, 1.5 to 261.7). During the median follow-up period of 27 months, complicated WON recurrence was observed in 5.3% of patients, and long-term complications occurred in 24.6% of patients (four exocrine insufficiency, nine newly developed diabetes mellitus, one recurrent small bowel obstruction, one chylous ascites). Conclusions: Considering that long-term complications are similar to those observed after pancreatectomy, DEN should be performed meticulously while minimizing damage to the viable pancreatic parenchyma with adequate antibiotic escalation. [ABSTRACT FROM AUTHOR]

Background/Aims: Interventional endoscopists may utilize contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) for image guidance during radiofrequency ablation (RFA) because of its capability to delineate real-time tumor perfusion dynamics. The purpose of this study was to assess the utility of CEH-EUS for the guidance and monitoring of endoscopic RFA. Methods: Nineteen consecutive patients with solid abdominal tumors who underwent CEH-EUS and endoscopic RFA were included. The extent of the ablation was assessed by CEH-EUS at 5 to 7 days after RFA. Additional RFAs were performed under CEH-EUS guidance. Results: The diagnoses were as follows: nonfunctioning neuroendocrine tumor (n=13), solid pseudopapillary neoplasm (SPN) (n=2), insulinoma (n=1), left adrenal adenoma (n=2), and left adrenal oligometastasis (n=1). Pre-CEH-EUS findings revealed that 17 cases showed hyperenhanced patterns and two cases of SPN showed isoenhanced patterns. CEH-EUS-assisted RFA was technically feasible in all 19 patients. After the first RFA session, seven patients of the treated tumors showed the disappearance of intratumoral enhancement on CEH-EUS, whereas 12 showed residual contrast enhancement. Twelve patients with incomplete ablation were further treated with additional RFA under real-time CEH-EUS guidance. Radiologic complete response was observed in 13 patients (68.4%). Among the 35 ablation procedures, the only adverse events were two episodes of pancreatitis (5.7%; 1 moderate and 1 mild). During the median follow-up of 28 months, the local recurrence rate was 7.7%. Conclusions: The application of CEH-EUS for RFA could be helpful in assessing early treatment response after ablation and targeting residual viable tumors during additional ablation sessions. [ABSTRACT FROM AUTHOR]

Background/Aims: The natural history of spontaneous decrease in the size of pancreatic cystic lesions (PCLs) without high-risk stigmata is under investigation. This study aimed to investigate the timing of spontaneous decrease in the size of PCLs without high-risk stigmata and to identify the characteristics associated with their complete resolution. Methods: From 2000 to 2016, patients with spontaneous decreases in PCL size on computed tomography (CT) and/or magnetic resonance imaging (MRI) who had at least 1 year of follow-up were evaluated retrospectively. Results: A total of 78 patients underwent follow-up for an average of 55.7 months. Most patients were asymptomatic, and 35 (37.2%) showed complete resolution. The initial mean PCL size was 1.6±0.9 cm (range, 0.5 to 5.6 cm). The average time to initial decrease in size and complete resolution of PCLs were 32.1 and 41.5 months, respectively. Compared with PCLs that completely resolved, presence of underlying malignancy was associated with partial resolution of PCLs in multivariable analysis (hazard ratio, 0.51; 95% confidence interval, 0.32 to 0.81; p=0.005). Endoscopic ultrasound (EUS) identified detailed findings, especially the presence of septum (p<0.001), calcification (p=0.015) and lobulation (p=0.001) that were not found on CT/MRI. Conclusions: Asymptomatic small PCLs without high-risk stigmata can naturally decrease in size at approximately 3 years, and complete resolution can be expected in the absence of underlying malignancy. Regular follow-up of approximately 3 years with EUS may be a reasonable and safe alternative when planning the initial treatment of small PCLs without high-risk stigmata. [ABSTRACT FROM AUTHOR]

Background/Aims: Type 2 autoimmune pancreatitis (AIP) has been considered extremely rare in East Asia. This study aimed to clarify the prevalence, clinical characteristics and radiological findings of type 2 AIP highlighting patients presenting as acute pancreatitis in a single center. Methods: Type 2 AIP patients were classified according to International Consensus Diagnostic Criteria. Radiological findings were compared between type 2 AIP presenting as acute pancreatitis and gallstone pancreatitis. Results: Among 244 patients with AIP, 27 (11.1%) had type 2 AIP (definite, 15 [55.5%] and probable 12 [44.5%]). The median age of patients with type 2 AIP was 29 years (interquartile range, 20 to 39 years). Acute pancreatitis was the most common initial presentation (n=17, 63%) while obstructive jaundice was present in only one patient. Ulcerative colitis (UC) was associated with type 2 AIP in 44.4% (12/27) of patients. Radiological pancreatic imaging such as delayed enhancement of diffusely enlarged pancreas, homogeneous enhancement of focal enlargement/ mass, absent/minimal peripancreatic fat infiltration or fluid collection, and multifocal main pancreatic duct narrowings were helpful for differentiating type 2 AIP from gallstone pancreatitis. During follow-up (median, 32.3 months), two patients (2/25, 8%) experienced relapse. Conclusions: In South Korea, type 2 AIP is not as rare as previously thought. Overall, the clinical profile of type 2 AIP was similar to that of Western countries. Type 2 AIP should be considered in young UC patients with acute pancreatitis of uncertain etiology. [ABSTRACT FROM AUTHOR]

Background/Aims: Differentially diagnosing focal-type autoimmune pancreatitis (f-AIP) and pancreatic cancer (PC) is challenging. Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) may provide information for differentiating pancreatic masses. In this study, we evaluated the usefulness of CEH-EUS in differentiating f-AIP from PC. Methods: Data were collected prospectively and analyzed on patients who underwent CEH-EUS between May 2014 and May 2015. Eighty consecutive patients were diagnosed with f-AIP or PC. PC and f-AIP were compared for enhancement intensity, contrast agent distribution, and internal vasculature. Results: The study group comprised 53 PC patients and 27 f-AIP patients (17 with type-1 AIP [15 definite and two probable], two with probable type-2 AIP, and eight with AIP, not otherwise specified). Hyper- to iso-enhancement in the arterial phase (f-AIP, 89% vs PC, 13%; p<0.05), homogeneous contrast agent distribution (f-AIP, 81% vs PC, 17%; p<0.05), and absent irregular internal vessels (f-AIP, 85% vs PC, 30%; p<0.05) were observed more frequently in the f-AIP group. The combination of CEH-EUS and enhancement intensity, absent irregular internal vessels improved the specificity (94%) in differentiating f-AIP from PC. Conclusions: CEH-EUS may be a useful noninvasive modality for differentially diagnosing f-AIP and PC. Combined CEH-EUS findings could improve the specificity of CEH-EUS in differentiating f-AIP from PC. [ABSTRACT FROM AUTHOR]

Background/Aims: The aim of this study was to establish a pathogenetic mechanism of pancreatitis in celiac disease and IgG4-related disease using gluten-sensitive human leukocyte antigen (HLA)-DQ8 transgenic mice. Methods: Transgenic mice expressing HLA-DQ8 genes were utilized. Control mice were not sensitized but were fed gliadin-free rice cereal. Experimental groups consisted of gliadin-sensitized and gliadin-challenged mice; nonsensitized mice with cerulein hyperstimulation; and gliadin-sensitized and gliadinchallenged mice with cerulein hyperstimulation. Results: Gliadin-sensitized and gliadin-challenged mice with cerulein hyperstimulation showed significant inflammatory cell infiltrates, fibrosis and acinar atrophy compared with the control mice and the other experimental groups. The immunohistochemical analysis showed greater IgG1-positive plasma cells in the inflammatory infiltrates of gliadin-sensitized and gliadin-challenged mice with cerulein hyperstimulation compared with the control mice and the other experimental groups. Gliadin-sensitized and gliadin-challenged mice with cerulein hyperstimulation or gliadin-sensitized and gliadinchallenged mice showed IgG1-stained inflammatory cell infiltrates in the extrapancreatic organs, including the bile ducts, salivary glands, kidneys, and lungs. Conclusions: Gliadinsensitization and cerulein hyperstimulation of gluten-sensitive HLA-DQ8 transgenic mice resulted in pancreatitis and extrapancreatic inflammation. This animal model suggests that chronic gliadin ingestion in a susceptible individual with the HLA-DQ8 molecule may be associated with pancreatitis and extrapancreatic inflammation. [ABSTRACT FROM AUTHOR]

Background/Aims: We aimed to evaluate the feasibility and efficacy of a forward-viewing linear endoscopic ultrasound (FV-EUS) in diagnostic EUS procedures compared to standard oblique-viewing EUS (OV-EUS). Methods: This study was a prospective, randomized study that permitted crossover. Fifty-one patients with subepithelial pancreatobiliary and upper gastrointestinal lesions underwent FV-EUS and OV-EUS sequentially, in random order. The EUS visualization was performed by a novice endosonographer, and the image quality of specific lesions was scored by an expert endosonographer. If fine-needle aspiration (FNA) was indicated, it was performed using both echoendoscopes by an expert endosonographer. Results: Both of the EUS procedures had similar visualization times and image quality. In general, the visualization time was inversely related to the diameter of the specific lesions. In subepithelial lesions of the stomach and duodenum, the visualization time (98.8±62.2 seconds vs 139.0±66.6 seconds, p=0.008) and image quality (4.1±1.3 vs 3.3±1.7, p=0.02) of FV-EUS were significantly superior to OV-EUS. FV-EUS-guided FNA of pancreatic masses was successful in seven patients (87.5%). Conclusions: FV-EUS may increase the ease of access to gastrointestinal subepithelial lesions compared to conventional OV-EUS. The performance of FV-EUS for evaluating pancreatobiliary diseases and performing interventions was comparable to conventional OVEUS. [ABSTRACT FROM AUTHOR]

Background/Aims: Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks. Methods: Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed. Results: In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases. Conclusions: ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients. [ABSTRACT FROM AUTHOR]

Background/Aims: High intensity focused ultrasound (HIFU) utilizes a targeted extracorporeal focused ultrasound beam to ablate neoplastic pancreatic tissue. We used an in vitro model to examine the effects of bone, metallic stents, plastic stents, metal plates, and cyst-like lesions on HIFU treatment. Methods: HIFU was delivered to the phantom models implanted with foreign bodies, and the location, shape, and size of the ablated zones were evaluated. Results: Bone and metallic plates reflected the ultrasound beam, shifting the ablation zone from the focal zone to the prefocal area. In the phantoms containing metal stent, plastic stent, and cyst, most of the ablative energy was reflected to the prefocal area by the surface, with the remainder penetrating through the phantom. The area of the ablated margins was significantly larger in size and volume than the intended focal ablation zone. Conclusions: During HIFU therapy, artificial or anatomical barriers could affect the direction of the ultrasound beams, shifting the ablation zone from the focal area to a prefocal site with a larger than expected ablation zone. These factors should be considered prior to HIFU treatment for pancreatic tumors because they could limit ablation success, in addition to causing complications. [ABSTRACT FROM AUTHOR]

Background/Aims: Although several groups have demonstrated the usefulness of natural orifice transluminal endoscopic surgery (NOTES), there is still concern about frequent serious adverse events. We performed this study to determine the technical feasibility and safety of pure NOTES with a transgastric approach in a porcine model from the endoscopist's point of view. Methods: Diagnostic peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation with a transgastric approach using a two-channel therapeutic endoscope were performed in 10 healthy female minipigs. These procedures were performed in two acute models and eight survival models in consecutive order. Results: The technical success rate was 100% for peritoneoscopy (10/10), liver biopsy (5/5), salpingo-oophorectomy (10/10), and Fallopian tube ligation (10/10). Eight cases of adverse events occurred, including one case of splenic injury, one case of bleeding after liver biopsy, two cases of small bowel adhesion after salpingo-oophorectomy, two cases of hematoma at the salphingo-oophorectomy site, and two cases of partial dehiscence at the gastric closure site. The gastric puncture site was closed with seven to eight hemoclips in four cases and two hemoclips and an endoloop in four cases. Conclusions: The use of pure NOTES for peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation may be technically feasible, but considerable adverse events can occur during or after the procedure. Further studies utilizing specialized techniques overcome several limitations of pure NOTES are therefore necessary. [ABSTRACT FROM AUTHOR]

Background/Aims Acute kidney injury (AKI) is a common complication in cirrhotic patients, but little is known of the impact of AKI in patients with variceal bleeding. This study evaluated the incidence of AKI using the International Club of Ascites-AKI criteria and their association with the prognosis of patients with variceal bleeding. Methods We performed a retrospective cohort study using the data of cirrhotic patients with acute variceal bleeding evaluated at Gyeongsang National University Changwon Hospital in Korea between January 2015 and June 2019. The association between AKI and mortality was examined via univariate and multivariate analyses using the Cox proportional hazard model Results A total of 134 episodes of acute variceal bleeding in 103 patients were enrolled. The sources of variceal bleeding were esophageal varices in 111 (82.8%) and gastric varices in 23 (17.2%). The mean age was 56.0 years. Over a mean follow-up period of 253.3 days, 57 patients (42.5%) of all the episodes developed AKI. At the diagnosis of AKI, 23 patients had stage 1a (40.4%), nine (15.8%) had stage 1b, 17 (29.8%) had stage 2, and eight (14.0%) had stage 3. In multivariate analysis, the independent factors for AKI were age per year (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.03 to 1.06) and Model For End-Stage Liver Diseases score (HR, 1.08; 95% CI, 1.03 to 1.14). The 42-day mortality rate was significantly higher in patients (n=20, 35.1%) with AKI than in patients without AKI (n=2, 2.6%, p<0.001). In addition, the presence of AKI was independent factor for 42-days mortality (HR, 5.58; 95% CI, 1.15 to 27.11). Conclusions AKI occurred frequently in patients with acute variceal bleeding. Our study proposes that AKI predicts mortality in patients with variceal bleeding. [ABSTRACT FROM AUTHOR]

Background/Aims Acute kidney injury (AKI) is a common complication in cirrhotic patients, but little is known of the impact of AKI in patients with variceal bleeding. This study evaluated the incidence of AKI using the International Club of Ascites-AKI criteria and their association with the prognosis of patients with variceal bleeding. Methods We performed a retrospective cohort study using the data of cirrhotic patients with acute variceal bleeding evaluated at Gyeongsang National University Changwon Hospital in Korea between January 2015 and June 2019. The association between AKI and mortality was examined via univariate and multivariate analyses using the cox proportional hazard model. Results A total of 134 episodes of acute variceal bleeding in 103 patients were enrolled. The sources of variceal bleeding were esophageal varices in 111 (82.8%) and gastric varices in 23 (17.2%). The mean age was 56.0 years. Over a mean follow-up period of 253.3 days, 57 patients (42.5%) of all the episodes developed AKI. At the diagnosis of AKI, 23 patients had stage 1a (40.4%), nine (15.8%) had stage 1b, 17 (29.8%) had stage 2, and eight (14.0%) had stage 3. In multivariate analysis, the independent factors for AKI were age per year (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.03 to 1.06) and Model For End-Stage Liver Diseases score (HR, 1.08; 95% CI, 1.03 to 1.14). The 42-day mortality rate was significantly higher in patients (n=20, 35.1%) with AKI than in patients without AKI (n=2, 2.6%, p<0.001). In addition, the presence of AKI was independent factor for 42-day mortality (HR, 5.58; 95% CI, 1.15 to 27.11). Conclusions AKI occurred frequently in patients with acute variceal bleeding. Our study proposes that AKI predicts mortality in patients with variceal bleeding. [ABSTRACT FROM AUTHOR]